The Checklist Manifesto

A quick summary and notes after reading the Checklist Manifesto by Atul Gawande.

The book starts by observing repeat errors which are simple, but have grave consequences which occur within surgery. The book then goes on a tour of a few other professions: construction and aviation, in order to learn better processes and find ways to avoid those repeat errors.

There are two types of checklists:

• Low-level checklists: essential things that everyone knows but missing one would be impactful
• High-level checklists: used to coordinate complicated processes when different disciplines must be involved

Low-level checklists

For example, a surgery team (see the WHO Surgical Safety Checklist) talking through the basics before they begin the operation. This rapidly builds a team out of a group of individuals which might not have worked together before:

• Everyone introduces themselves: name and role
• Discuss the plan
• Potential concerns
• How they would handle trouble

Another type of checklist is for routine tasks that must be completed for a certain goal. Checklists should include the critical items, the ones which even experienced professionals can forget. Don’t include things that aren’t critical, (e.g. pilots would never forget to communicate with the flight attendants or the tower), those are part of another process the professionals should already know.

High-level checklists

High-level checklists are used when the whole project is too complex for any one person to be able to keep track or understand the whole. The book contrasts the master builder of old, who was able to understand and be an expert in, all the different trades involved in building a structure with the current day construction project manager who can not possibly have the same depth of understanding of the complex trades involved in modern-day construction. In that case, multiple functions must communicate together, at different stages of the process to decide on how to proceed given recent developments. This is leaderless assembly where all the different roles must agree on the way forward in order to proceed.

All approvals or conversations should have a time limit to reach a conclusion e.g. need to arrive at a decision within 5 days of this stage ending; I need an approval from your role within 3 days.

Checklist best practices

Checklists should ideally be 5-9 items long.

A checklist is either a do-confirm or a read-do checklist. Do-confirm means that the people carry out the tasks from memory and then double-check with the list.

Prioritize keeping the checklists up to date against keeping the manual up to date. The checklists are used and referenced in an emergency or other critical situation. The manuals are read and can be edited at ease.

Personal notes

The biggest surprise I had was how challenging the author found it to convince surgeons to adopt a checklist, at the expense of their perceived independence and power. A big part of the book seems to be dedicated to justifying the effectiveness of checklists to skeptic (surgeons) adopters. Maybe my surprise is a consequence of me reading the book years after it’s been published and after it’s been somewhat absorbed into (software development) professional culture. I expected this book to be more of a manual about how to design and use checklists.

I learned about the power and responsibility that nurses have in the practice of medicine. They design processes as well as ensure they are followed. They are also expected to hold doctors to account against established processes and best practices.